Quality Improvement: Lessons for Workers’ Compensation Quality of Care

1. Quality Improvement: Lessons for Workers’ Compensation Quality of Care Linda Rudolph, MD, MPH Medi-Cal Managed Care Division CA Department of Health Services May 1, 2003

2. What Do We Want?Quality • “The degree to which health services for individuals and populations increase the likelihood of desired patient outcomes given the current state of knowledge” IOM, 1990 • The extent to which health services meet their aim – improving health.

3. accessible competent state of the art caring trusting patient-oriented patient-selected reasonably priced coordinated continuous What Do We Want? (DWC Focus Groups) DWC, Improving the QOC for Injured Workers, 2001

4. Safe Effective Efficient Timely Patient Centered Equitable What Do We Want?(Institute of Medicine) IOM, Crossing the Quality Chasm, 2001

5. What Do We Have?

6. What Do We Have? • Distrust • Poor access to specialists • Delays in care • Fragmentation and lack of continuity • Care not patient-centered • Inefficient and ineffective care • No accountability Improving the Quality of Care for Injured Workers: Focus Group Discussions. DWC. 2001

7. “Every system is perfectly designed to produce the results that it does achieve.” (Berwick/Batalden)

8. What can we do? • Accountability • Improvement

9. Accountability • Policies and contracts • Monitoring • Measurement • Reporting

10. You can’t fatten a calf by weighing it….Palestinian proverb

11. Improvement A systematic program for taking a system from one level of performance to a higher level of performance

12. Low Back Pain • ¼w.c. claims • 1/3 w.c. costs

13. What Do We Have? • Care highly variable • Care inconsistent with guidelines • Patient outcomes poor

14. Theory of Change • Will • Ideas • Execution/supporting change

15. Low Back Pain = Chronic Illness

16. Care Model for Worker Health(adapted from IHI/Dr. Ed Wagoner)

17. Resources and Policies • Resources to support injured workers and providers are easily accessible • Insurers, State agencies, employers, and health care providers: • coordinate and partner with each other around worker and injured worker needs • promote and offer evidence-based effective interventions and programs • System incentives are aligned for policy (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

18. Health and W.C. System • Specific goals for prevention and care management are part of the strategic and business plan. • Senior leadership is committed to meeting the needs of injured workers.Encourage coordination among primary care and occupational medicine care • System has adopted an effective performance improvement model. • Incentives support these organizational goals. (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

19. Self-Management Support • Emphasize worker’s active and central role in managing illness • Resources available to increase patient knowledge, confidence, and skills • Workers assisted in setting shared goals • Workers have access to peer support • Workers assisted in improving communication with providers about health care. (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

20. Decision Support • Evidence-based guidelines and protocols integrated into practice systems • Integrated expertise (occ med, specialists, mental health,w.c., workplace) • Care team works to maximize cooperation, continuity, and patient outcomes • Use of modalities proven to change practice behavior (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

21. Delivery System Design • Practice anticipates problems, provides services to maintain QOL and function • Roles/responsibilities of team members defined, appropriate training provided • Systems designed for regular communication and f/u (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

22. Clinical Information System • Registry of patients in need of services maintained • Reminder system used for patients and care team • Information system provides regular feedback to care team • System allows for care planning (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

23. Model for Improvement

24. Aims • Reduce plain x-rays • Reduce opiate prescriptions • Increase patient self-management education • Increase availability of modified work

25. From Aim to Improvement • Define measures (process, outcome) • Barrier analysis • Identify available interventions • Identify target population • Outreach • Implement interventions: • Did it work? • Start again!

26. Quality Improvement Collaboratives • Medi-Care • Medi-Cal • Pursuing Perfection/Rewarding Results • CPCA (HRSA) • DHS • CCHRI